Breast Thermography.Org

ACADEMY of MEDICAL INFRARED TRAINING
ThermoDoc® Network

ACADEMY of MEDICAL INFRARED TRAINING
ThermoDoc® Network
REGISTRATION FORM

Next Program April 29 – May 2, 2010

Breast and Neuro-musculo-skeletal Program
All registrations must be received by April 10, 2010

Please complete this form and return with payment to the above address.
Make check payable to William Cockburn, DC, FIACT, FABFE


A $250.00 non refundable fee will be applied per applicant for all cancellations

NAME: __________________________________ Degree: __________

CLINIC NAME: _______________________________________________________

ADDRESS:____________________________________________________________

CITY/STATE/ZIP:______________________________________________________

PHONE: _______________________________________________________________

E-MAIL: _______________________________________________________________

NUMBER OF YEARS IN THERMAL IMAGING: _________________________

TYPE OF EQUIPMENT YOU USE: ____________________________________

LEVEL OF INTEREST IN COMPLETING DIPLOMATE STATUS IN DVD
BASED MODULES: ___________________________________________________

Membership in Thermography Organizations: _________________________________________________

Page One of Two

ACADEMY of MEDICAL INFRARED TRAINING
ThermoDoc® Network
REGISTRATION FORM
Po Box 2382
Whittier, CA 90610-2382
(562) 699-7921 Fax- (562) 695-2439

• Two  and Four Day Programs    
Next Program

April 29 – May 2, 2010

Breast )Thursday - Friday) or Musculo-Skeletal/Pain (Sat - Sun) 

Initial Attendee $1,800.00 $______________
Additional Attendee(s) $900.00 X ___ $______________Must be from the same office or practice
List Names for each additional attendee:________________________________________________________________

Total Enclosed $_____________

• Four Day Program Breast (Thur/Fri) & Musculo-Skeletal/Pain (Sat/Sun) 

Initial Attendee $3,400.00 $______________
Additional Attendee(s) $1,500.00 X ___ $______________Must be from the same office or practice
List Names for each additional attendee:________________________________________________________________

Total Enclosed $_____________

Total Enclosed $_____________

Please make out to: Dr William Cockburn

Fax these two pages to: Dr William Cockburn (562) 695-2439 for scheduling
Mail Payment to: Dr William Cockburn

PO Box 2382 Whittier, California 90610-2382

ACADEMY of MEDICAL INFRARED TRAINING
ThermoDoc® Network
REGISTRATION FORM
Po Box 2382
Whittier, CA 90610-2382
(562) 699-7921 Fax- (562) 695-2439

Your Instructor:

Dr William Cockburn has been in private practice since 1975 and was first Board Certified in Clinical Thermal Imaging in 1985. He is also Board Certified in Radiology, Workers Compensation Law and Disability Evaluation. Dr Cockburn maintains two thermal imaging practices in the greater Los Angeles area. Having been Boarded by the CTS, ITS, IACT, AMII, Dr Cockburn brings a wealth of Educational, Practice and Management experience to the clinician student. This program is regularly updated and has been taught since 1999.

Location:

If you have any problems, please call Dr Cockburn at (562) 699-7921 Office

thermodoc@verizon.net